The bleaching technique
Professor Meningaud - Maxillofacial Surgery at Paris Est Créteil
The use of soft tissue fillers has grown considerably due to the increasing popularity of minimally invasive cosmetic procedures. The common principle of injections in aesthetic medicine is to treat and prevent the signs of ageing with as little product and as precisely and effectively as possible. The ‘blanching’ technique meets these specifications perfectly. It uses a very fluid hyaluronic acid, which the body evacuates very quickly and naturally.
It is injected ultra-superficially, resulting in the formation of small white papules at the level of the wrinkle (hence the name of the technique), which disappear in less than ten minutes.
Key points
– Bleaching typically uses 30 gauge needles
– The needle is roughly parallel to the skin, with a penetration angle of less than 12 degrees.
– Once the first papule has formed, the needle must be withdrawn and reinserted around the perimeter of the first papule to create a second papule.
– If the injection is painful, haemorrhagic and does not produce whiteness, it is too deep.
Introduction
Skin ageing is induced by both intrinsic and extrinsic factors. Intrinsic ageing is an inevitable physiological process that results in thin, dry skin, fine wrinkles and progressive skin atrophy, while extrinsic ageing is caused by external environmental factors such as air pollution, smoking, poor diet and sun exposure, resulting in skin laxity, deep wrinkles and loss of elasticity. Since 2000, minimally invasive cosmetic procedures have increased by 300% (1). Among the most commonly used minimally invasive cosmetic procedures, soft tissue fillers are second only to neuromodulators. According to statistics from the American Society for Aesthetic Plastic Surgery, >1.6 million hyaluronic acid (HA) filling procedures were performed in 2014 in the US, making it the second most widely used non-surgical aesthetic procedure after botulinum toxin.
Hyaluronic acid injection techniques have evolved considerably, with motorised cannulas and devices in particular. They have become safer and more predictable. However, there is one technique that I feel has not been sufficiently developed, even though it gives excellent results: the ‘blanching technique’. I have observed that it is often poorly mastered. The purpose of this article is to share my technical tips with you. For a more complete account, I recommend reading the articles by Micheels P, who has been reporting on the subject in international journals since 2012.
The blanching technique
Bleaching traditionally uses 30 gauge and 13 mm needles. I tend to use 32 gauge needles, which are slightly shorter (8mm). The needle is roughly parallel to the skin, with a penetration angle of less than 12 degrees. In practice, you need to be as tangent as possible. To ensure superficial intradermal injection, the outline of the needle should be visualised by slightly lifting the needle under the skin (‘tenting’). To avoid placing the hyaluronic acid too superficially, the bevel should be turned downwards if the skin is thin. Several injections are made very close together, depositing small quantities of the product. This injection close to the surface creates a temporary whiteness and then a small papule. Once the first papule has formed, the needle must be withdrawn and reinserted around the perimeter of the first papule to create a second papule. And so on, until the wrinkle is completely erased. If a lip is treated, for example, it should be uniformly white at the end of the procedure. Post-injection modelling ensures the final smoothing.
The term ‘blanching’ is used to describe an immediate and brief (less than 10 minutes) benign local whitening in the superficial area injected. Whereas after a deeper injection, local pallor should initially give rise to fears of arterial embolisation of the filler, with the blanching technique there is no vascular risk. No Tyndall effect has been observed (11). As the injection is very superficial, it is not very painful. The bleeding caused must be very small. If the injection is painful, haemorrhagic and does not cause blanching, it is too deep. To make the procedure easier, I recommend the use of magnifying glasses and a motorised injection pen. The small volume of hyaluronic acid used per wrinkle means that many areas can be treated effectively. Patients should be made aware of the existence of papules. Depending on the product used, they may last from 2 to 5 days. It is essential that the patient massages them from the very first day, applying fairly strong pressure as if to crush them. Vitro-pressure is also a good technique.
The aim is to distribute the hyaluronic acid even more evenly in the superficial dermis. These papules are essential to the result. Hyaluronic acid creates a kind of ‘scaffolding’ within the superficial dermis and its tissue-inducing properties contribute to collagen synthesis. In this way, long-lasting results can be obtained, sometimes up to 2 years, even for stubborn or long-established fine lines. The principle is that of tissue induction, and not simply a wrinkle filling effect (filling is only useful to guide collagen synthesis). As a result, some cases are more difficult than others. As a general rule, smoking, oestrogen deficiency (particularly in cases of breast cancer) and advanced age are limiting factors. The best cases are found among non-smoking women aged 50 who are still taking hormones or on HRT. For men, the most popular area is the forehead. The main limiting factor is smoking. As the skin is usually thicker, the results are often very good.
Conclusion
Provided the indications are clearly defined (as is always the case in medicine), the blanching technique can give excellent results. It can complement the results of conventional techniques for deep wrinkles. Its aim is to treat superficial collagen breakage. It can sometimes be used to treat stubborn wrinkles such as bitterness folds, scars or vertical wrinkles on the upper lip (‘bar codes’). Although it seems simple, this technique requires training. The learning curve is spread over several months.
References
1- American Society of Plastic Surgeons. Plastic surgery statistics report, 2017. Accessed November12,2018.Availableat https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf.
2- Lorenc ZP, Fagien S, Flynn TC, Waldorf HA. Review of key Belotero Balance safety and efficacy trials. Plast Reconstr Surg. 2013 Oct; 132(4 Suppl 2):33S-40S.
3- Necas J, Bartosikova L, Brauner P, Kolar J. Hyaluronic acid (hyaluronan): a review. Vet Med. 2008;53(8):397–411.
4- Stocks D, Sundaram H, Michaels J, Durrani MJ, Wortzman MS, Nelson DB . Rheological evaluation of the physical properties of hyaluronic acid dermal fillers. J Drugs Dermatol. 2011 Sep; 10(9):974-80.
5- Kablik J, Monheit GD, Yu L, Chang G, Gershkovich. Comparative physical properties of hyaluronic acid dermal fillers. J Dermatol Surg. 2009 Feb; 35 Suppl 1():302-12.
6- Prager W, Steinkraus V. A prospective, rater-blind, randomized comparison of the effectiveness and tolerability of Belotero® Basic versus Restylane® for correction of nasolabial folds. Eur J Dermatol. 2010;20(6):748–752.
7- Wollina U, Goldman A. Hyaluronic acid dermal fillers: safety and efficacy for the treatment of wrinkles, aging skin, body sculpturing and medical conditions. Clin Med Rev Ther. 2011;3:107–121.
8- Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;6:295–316.
9- Tran C, Carraux P, Micheels P, Kaya G, Salomon D. In vivo bio-integration of three hyaluronic acid fillers in human skin: a histological study. Dermatology. 2014;228(1):47–54.
10- Prasetyo AD, Prager W, Rubin MG, Moretti EA, Nikolis A. Hyaluronic acid fillers with cohesive polydensified matrix for soft-tissue augmentation and rejuvenation: a literature review. Clin Cosmet Investig Dermatol. 2016 Sep 8;9:257-80.
11- Micheels P, Sarazin D, Besse S, et al. A blanching technique for in‐ tradermal injection of the hyaluronic acid Belotero®. Plast Reconstr Surg. 2013;132:69S‐76S.
12- Micheels P, Besse S, Flynn TC, et al. Superficial dermal injection of hyaluronic acid soft tissue fillers: comparative Ultrasound study. Dermatol Surg. 2012;38:1162‐1169.